The gluten debate rages on. There are those who eat it (it is, in fact, one of the most heavily consumed proteins on earth). Then there are those who abstain. A 2014 report by Mintel found that 15% of households in the UK were avoiding gluten and wheat. Now, increasingly, there are those who mock the abstainers, dismissing the gluten-free hype as quackery (there was even an entire episode of South Park devoted to ridiculing the craze). But could this backlash against the gluten-free movement be even more damaging than the trend itself? By trivialising what it is to be gluten-free, could we be in danger of trivialising for what in a certain proportion of the population is a genuine medical condition?

We look at the latest evidence on the area of gluten-related disorders, in an attempt to separate the wheat from the chaff. Or, rather, the scientific facts from the hype…

Gluten-related disorders

'Gluten-related disorders' is an umbrella term used for all diseases triggered by gluten - the protein found in wheat, spelt, rye and barley.

It includes the following:

Coeliac Disease: An autoimmune disorder that often runs in families. When an individual with coeliac disease eats gluten, the body launches an immune attack on the intestinal lining. This damages the lining and prevents nutrients from being absorbed into the body. This leads to nutritional deficiencies and a number of related health problems and symptoms. Around 1% of the population are thought to suffer from coeliac disease – and of those, nearly three-quarters remain undiagnosed. The only treatment for coeliac disease is a strict lifelong gluten-free diet.

Wheat allergy: An immune reaction to wheat that occurs within minutes to hours after wheat exposure. Diagnosis is made through skin prick tests, wheat-specific IgE blood testing and a food challenge. Wheat allergy is relatively rare and probably affects under 1% of the population. Sufferers either need to follow a wheat-free or gluten-free diet, depending on the nature of the allergy.

Coeliac disease and wheat allergy have long been medically recognised, and have a very distinct diagnosis, but in recent years it has become acknowledged that an adverse reaction to gluten can also occur in individuals who don't suffer from one of these conditions. In 2012, a new type of gluten-related disorder was categorised and labelled non-coeliac gluten sensitivity.

What is non-coeliac gluten sensitivity?

So far, non-coeliac gluten sensitivity has mostly been defined by what it's not. Meaning, it's not coeliac disease and it's not a wheat allergy. Similar to IBS (which, incidentally, presents with many of the same symptoms), non-coeliac gluten sensitivity can be defined as a diagnosis of exclusion, made once coeliac disease and wheat allergy have been ruled out. It is characterised by symptoms that usually occur after eating gluten, disappear with gluten withdrawal from diet, and relapse following reintroduction of gluten. However, at present there is no diagnostic test for this condition.

How common is non-coeliac gluten sensitivity?

The overall prevalence of non-coeliac gluten sensitivity in the general population is unknown, largely due to the fact that many people self-diagnose and start a gluten-free diet of their own accord without consulting a medical professional. And you should always consult a certified medical professional if you suspect something is up. Some experts believe that the incidence of non-coeliac gluten sensitivity is likely to be higher than coeliac disease and wheat allergy, with its estimated numbers affecting 0.63–6% of the population.

Could it be that gluten isn't the culprit?

Whilst non-coeliac gluten sensitivity is a recognised condition, emerging research indicates that for some people it might not actually be gluten causing their digestive symptoms, but malabsorption of a group of fermentable carbohydrates known as FODMAPs explains Charlene Grosse, Accredited Practicing Dietitian and Spokesperson for the DAA:

"FODMAPs include a range of foods like certain fruits (apples, pears), vegetables (leeks, onions, garlic), dairy products and legumes. A study at Monash University in 2013 studied a group of people who reported gluten made them worse, although they did not have coeliac disease. A low FODMAP diet significantly reduced their symptoms. Participants who had reported improvements in GI symptoms on a gluten free diet before the study had even fewer symptoms on a low FODMAP diet."

Of further interest, was what occurred when participants were given gluten after the low FODMAP diet:

"When gluten was challenged with these participants up to the equivalent of 10 slices of wheat bread, there was no difference in symptoms. In other words, gluten had no effect on symptoms."

This says Charlene, has led to much debate about whether non-coeliac gluten sensitivity is a distinct clinical diagnosis.

What should you do if you suspect non-coeliac gluten sensitivity?

It is not recommended that individuals embark on a gluten-free diet without professional guidance, as there is a risk of becoming low in fibre and B vitamins if this is not done properly.

"If you are experiencing gastrointestinal symptoms and your GP or gastroenterologist has ruled out coeliac disease, see a Dietitian with an interest in gut health and digestive diseases," advises Charlene. "They can help you identify if foods are a trigger, and how to manage your symptoms while optimising your food variety."

The conclusion? Further research is required

Whilst research into non-coeliac gluten sensitivity has developed considerably over the last few years, this still remains a controversial area. More research is required to understand the exact nature of this condition, and how a definitive diagnosis can be made.

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